1 King Making Sense of Advance Directives (1991) 32; [ Links ] Kruse "A Call for New Perspectives for Living Wills (you might like it here)" 2002 Probate and Trust Journal 545 546-549. [ Links ]2 In terms of s 1 of the National Health Act 61 of 2003 the moment of death is defined as "brain death", which is defined as "an irreversible and irreparable cessation of all the brainstem functions inclusive of complete cessation of the heartbeat, respiration, blood circulation and digestive functions" Carstens and Pearmain Foundational Principles of South African Medical Law (2007) 204 n 433. This definition of death is accepted in other jurisdictions as well but defining death remains problematic and controversial. See Herring Medical Law and Ethics (2010) 464-469 for a discussion of alternative definitions of death. 3 Camhi, Mercado, Morrison, Du, Platt, August and Nelson "Deciding in the Dark - Advance Directives and Continuation of Treatment in Chronic Critical Illness" 2009 Critical Care Medicine 919. [ Links ]4 Brown "The Law and Practice associated with Advance Directives in Canada and Australia: Similarities, Differences and Debates" 2003 Journal of Law and Medicine 59 60 points out that the first "living wills" were letters that individuals wrote to their families and loved ones stating that they would not want to have their life extended artificially if they were no longer competent to make these decisions for themselves. [ Links ]5Castell v De Greeff 1994 4 SA 408 (C) 420J; 422 H-J, citing Van Oosten The Doctrine of Informed Consent in Medical Law (LLD dissertation 1989 UNISA) 414. 6 420H-J; 425H-I. 7 Van Oosten 414. 8 421C. 9 McQuoid-Mason "The Legal Status of the 'Living Will' 1993 Continuing Medical Education 59; [ Links ] McQuoid-Mason "Pacemakers and Living Wills: Does turning down a Pacemaker to allow Death with Dignity constitute Murder?" 2005 SACJ 24 27. The theoretical premise is of course, not always similar to the de factoposition in practice. As pointed out by Biggs Euthanasia, Death with Dignity and the Law(2001) 103 many patients give or refuse consent without fully understanding the implications of the medical intervention or treatment that is proposed. Patients do not always understand the language used by physicians which presupposes a good knowledge of the workings of the human body. Many patients also blindly trust their physicians to know better than they do as to what is in their best interest. 10 Wills Act 7 of 1953. 11 1992 4 SA 630 (D). 12 A permanent vegetative state was explained by Thirion J in Clarke v Hurst 1992 4 SA 630 (D) 640D-F as "a neurological condition where the subject retains the capacity to maintain the vegetative part of neurological function but has no cognitive function. In such a state the body is functioning entirely in terms of its internal controls. It maintains digestive activity, the reflex activity of muscles and nerves for low level and primitive conditioned responses to stimuli, blood circulation, respiration and certain other biological functions but there is no behavioural evidence of either self-awareness or awareness of the surroundings in a learned manner". 13 633J-A. 14 633J-634A. 15 660B-C. The court based its finding on the more flexible criterion for legal causation introduced in S v Mokgethi1990 1 SA 32 (A), namely whether policy considerations of reasonableness, fairness and justice require that an act is viewed as the legal cause of a result. 16 653-657. 17 660D-F. 18 660E. 19 Strauss "The 'right to die' or 'passive euthanasia': Two Important Decisions, One American and the Other South African" 1993 SACJ 196 208 who regrets the court's reluctance to give explicit recognition to living wills; [ Links ] Fleischer "End-of-life Decisions and the Law: A New Law for South Africa?" 2003 (21) Continuing Medical Education 20; McQuoid-Mason 59. 20 South African Law Commission "Report on Euthanasia and the Artificial Preservation of Life" (1998) RP 186/1999. 21 In the "Summary of Recommendations" of the report. For critical discussions of the recommendations, see Landman "Legalising Advance Directives in South Africa 2000 SA Medical J 785 786-787; Fleischer 22-25. 22 Strauss Doctor, Patient and the Law: A Selection of Practical Issues (1984) 387. 23Clarke v Hurst 1992 4 SA 630 (D).24 Strauss 344-345. 25 345. 26 McQuoid-Mason 2005 SACJ 27-28; Carstens and Pearmain 209; Burchell Principles of Criminal law (2006) 328. 27 The rest of s 7 sets out a hierarchy of persons who may consent on behalf of the user if he or she is unable to consent and no person has been mandated or authorised to give such consent. 28 McQuoid-Mason "Advance Directives and the National Health Act" 2006 SA Medical J 1236 1237. [ Links ]29 See the views of McQuoid-Mason 1237. 30 Health Professions Council of South Africa (HPCSA) Guidelines for Good Practice in the Health Care Professions (2008) booklet 12 "Guidelines for the Withholding and Withdrawing of Treatment". 31 Par 2.1 of booklet 9. 32 Par 2.3 and 3.11 of booklet 9. 33 Par 2.1 of booklet 12. 34 Par 2.1. 35 Par 2.3. 36 Par 2.3. 37 Par 2.3. 38 Par 8. Of course in the case of children it is required that their decisions to refuse health care should be respected, provided they have legal capacity to make such decisions and it is in the child's best interests. If the practitioner believes that such refusal is not in the child's best interests, he or she should approach the court for a decision. See par 14 of booklet 12 of the HPCSA guidelines. 39 S 10 of the Constitution provides: "Everyone has inherent dignity and the right to have their dignity respected and protected". Currie and De Waal The Bill of Rights Handbook (2008) 272 describe "human dignity" as "a central value of the 'objective normative value system' established by the Constitution, perhaps the pre-eminent value" (citing the Constitutional Court in Carmichele v Minister of Safety and Security 2001 4 SA 938 (CC) par 56). These writers point out that the origins of the concept can be traced to Kantian moral values according to which human dignity gives a person intrinsic worth. In S v Dodo 2001 3 SA 382 (CC) par 38 Ackerman J emphasised that "[h]uman beings are not commodities to which a price can be attached, they are creatures with inherent worth and infinite worth; they ought to be treated as ends in themselves, never merely as means to an end". 40 S 12(2)(b) provides: "Everyone has the right to bodily and psychological integrity which includes the right to security and control over their body". 41 S 14 provides that everyone has the right to privacy, which shall include the right not to (a) have their person or home searched; (b) their property searched (c) their possessions seized; or (d) the privacy of their communications infringed. 42 The relevant parts of s 9 provide that (1) everyone is equal before the law and has the right to equal protection and benefit of the law; (2) that to promote the achievement of equality, legislative and other measures designed to protect or advance persons, or categories of persons, disadvantaged by unfair discrimination may be taken and (3) that the state may not unfairly discriminate directly or indirectly against anyone on one or more grounds, including, race, gender, sex, pregnancy, marital status, ethnic or social origin, colour, sexual orientation, age, disability, religion, conscience, belief, culture, language and birth and (4) that national legislation must be enacted to prevent or prohibit unfair discrimination. 43 Van Oosten 441 states that "the cardinal principle of self-determination still demands that the ultimate and informed decision to undergo or refuse [a medical] intervention should be that of the patient and not that of the doctor" (cited in Castell v De Greeff422J-423A). 44 Gray and Smith (eds) JS Mill' On Liberty ' in Focus (1991) 30. 45 Olick Taking Advance Directives Seriously (2001) 46 defends "a deeper claim about the importance of the principle of prospective autonomy". He argues that "future-oriented decisions are integral to the life of autonomous persons, no less concerning the way we die than the way we live". 46 Dworkin Life's Dominion: An Argument about Abortion, Euthanasia and Individual Freedom (1993) 200-213. 47 In Bernstein v Bester 1996 2 SA 751 (CC) par 67 Ackerman J stated that it would be reasonable to expect privacy "in the inner sanctum of a person ..." that lies in the "truly personal realm...". He also referred ( par 73) to the Council of Europe's view of the right to privacy, namely that it "consists essentially in the right to live one's own life with a minimum of interference". 48Harksen v Lane 1988 1 SA 300 (CC) par 53. 49 1996 6 BCLR 752 (CC) paras 41-44. 50 See also Currie and De Waal Bill of Rights Handbook (2008) 233: "Formal equality means sameness of treatment: the law must treat individuals in like circumstances alike. Substantive equality requires the law to ensure equality of outcome ." 51 Olick 13: "Equating the rights of incompetent patients with those of competent patients also embraces the law's long-standing commitment to equality and to protection of disabled and vulnerable persons from discrimination and abuse. The value of human dignity and worth extends to all persons equally, not just to competent and healthy persons. To conclude otherwise would ... do violence to incompetent patients' interests in self-determination ..." 52 In the United States treatment has been forced on unwilling pregnant patients on grounds such as "the unborn child's right to live and "the state's compelling interest in preserving the life of the foetus" (Jefferson v Griffin Spalding Country Hospital Authority(1981) 274 SE 2d 457)). Currently, a majority of the states have legislation which specifically addresses the status of an advance directive of a pregnant but incompetent woman. The legislation varies considerably. In seventeen of the states, advance directive of pregnant women have no binding effect irrespective of the stage of development of the foetus. In other states a balance between the constitutional rights of an incompetent woman and the interest of the state to protect potential life is sought by criteria such as the "probability" that the foetus will develop to live birth if the treatment is administered. Pregnancy clauses have not been found to be unconstitutional under United States jurisprudence. See Sperling "Do Pregnant Women have (living) will?" 2005 Journal of Health Care Law and Policy331 336-340. He argues (333) that since there is no specific provision which deals with the status of advance directives of pregnant women in Canadian law, it seems as if "Canadian law treats the incompetent pregnant woman who issued an advance directive while competent the same way as it treats other incompetent patients, that is, it respects the patient's right to control her medical decisions". The South African Law Commission also did not consider this particular issue in its "Report on Euthanasia and the Artificial Preservation of Life". In the United Kingdom, absolute value is attached to the right of a competent pregnant woman to refuse medical treatment even if she is in the final stages of pregnancy and her own life and that of the unborn child depend on such treatment and even if her decision appears "morally repugnant" (St George's Healthcare NHS Trust v S [1998] 3 All ER 673 692a-c). There is also no provision in the United Kingdom legislation ( The Mental Capacity Act 20055) that an advance directive refusing life-saving treatment would not apply if the patient were pregnant with a viable foetus. Therefore, an advance refusal would be regarded as enforceable in such circumstances, provided that the advance directive is clear and there is no reason to believe that the patient did not anticipate that she would be pregnant at the crucial time. (See s 25(4) of the Mental Capacity Act 2005)53 See Christian Lawyers ' Association v Minister of Health 2004 10 BCLR 1086 (T); S v Mshumpa 2008 (1) SACR 126 (E) par 56; Road Accident Fund v Mtati 2005 6 SA 215 (SCA). 54 S 2(c)(i) and s 2(c)(ii) of the Choice on Termination of Pregnancy Act 92 of 1996. 55 See Neeley The Constitutional Right to Suicide: A Legal and Philosophical Examination (1994) 148, citing Jacobson v Massachusetss 197 U.S. 11 (1905). 56 1995 3 SA 391 (CC). 57 Par 269. 58 Paras 326-327. Singer "Rethinking Life and Death" (1994) 75 argues that in the contemporary age considerations as to the quality of life are an inherent feature of medical practice. Dworkin 210 emphasises, however, that it is not every kind of dependent life of a person with a severe handicap that is not worth living. He refers, for example to the meaningful life of the brilliant scientist Stephen Hawking and millions of other ordinary people who lead valuable lives despite being handicapped. But, in his view (210) "[t]otal or near-total dependence with nothing positive to redeem it may seem not only to add nothing to the overall quality of a life but to take something important from it." This is particularly the case where there is no comprehension that care is given. 59 Herring 499-501 ; Huxtable Euthanasia, Ethics and the Law: From Conflict to Compromise (2007) 133-140. 60 Huxtable 133-140. 61Idem 136-137. 62Idem 11 and 135. 63 King 47 argues that although an attempt to commit suicide is no longer punishable, prevention of suicide is a legitimate beneficent concern in cases where the would-be suicide lacks the mental capacity to make an autonomous decision. She points out, however, that American courts have held that prevention of suicide is not a legitimate societal concern in cases of refusal of medical treatment. 64 I 47 gives the example of a Jehovah's witness who refuses blood not in order to die but in order to avoid damnation. Likewise, patients who refuse to stay on artificial respiration do not necessarily wish to die. Herring 476 explains that the general view is that "suicide involves a person intentionally killing themselves". If the patient refuses treatment because he or she wants to die then it could be viewed as suicide, but if the patient's act is not prompted by continued on next page the desire to kill herself or himself (even if death is foreseen) then the act is permissible. But Herring 541 points out that there may be cases where a patient refuses treatment with the purpose of committing suicide. He gives the example of a teenager who has a septic cut and refuses treatment because he has been disappointed in love. But in such instances where the decision is assessed by the courts as "utterly unreasonable" the patient is declared incompetent. 65 Perry " Legal Implications for Failure to comply with Advance Directives: An Examination of the Incompetent Individual's Right to refuse Life-Sustaining Medical Treatment" 2002 Behavioral Sciences and the Law 253 257 cites the case of Superintendent of Belchertown State School v Joseph Saikewicz 370 NE 2d 417 426-427 (1977) in support of his statement that American courts "rarely find that state interests [such as preservation of life] are sufficiently compelling to deny an individual's right to refuse medical treatment". 66 Proponents of this argument are, inter alia, Keown Euthanasia, Ethics and Public Policy - An Argument against Legalisation (2002) 37-80 and Amarasekara and Bagaric "Moving from Voluntary Euthanasia to Non-Voluntary Euthanasia: Equality and Compassion" 2004 Ratio Iuris398.67Cf the views of Porter "Advance Directives and the Persistent Vegetative State in Victoria: A Human Rights Perspective" 2005 Journal of Law and Medicine 256. She points out (261-262) that the right to life is concerned with the prevention of arbitrary taking of life which is a threat to the existence of society and that it is not violated where a person is allowed to die following the withdrawing or withholding of treatment in accordance with a person's previously expressed wishes. 68 S 39(2) of the Constitution of the Republic of South Africa, 1996 provides that a court, when developing the common law, must promote the spirit, purport and objects of the Bill of Rights. Since the inception of the Constitution the Constitutional Court and the Supreme Court of Appeal have ruled in a number of cases that the common law should be developed in terms of these values, norms and objects. See Carmichele v Minister of Safety and Security2001 4 SA 938 (CC); Van Eeden v Minister of Safety and Security 2003 1 SA 389 (SCA); Minister of Safety and Security v Van Duivenboden 2002 6 SA 431 (SCA); Minister of Safety and Security v Hamilton 2004 2 SA 216 (SCA).